The Red Eye

[KLPM]

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I know that there are a lot of causes for the red eye but I was wondering about distinguishing between 3 things specifically: conjunctivitis, episcleritis, scleritis.

How are these entities distinguished on history and examinations?

I know that they affect different "planes" surrounding the eyes but how do they look different. I have seen a lot of pictures in books that label things as any of the above but often I have difficulty telling them apart based on the picture.

Sometimes there are other clues that point me towards something. For instance conjunctivitis may also have lid swelling. Very occasionally I might be able to see the "darker" hue of scleritis. But a lot of the time I am just guessing what is what.

I have also read about using phenylephrine at 2.5% or 10% to check for blanching of vessels?

 

[PBEA]

I know that there are a lot of causes for the red eye but I was wondering about distinguishing between 3 things specifically: conjunctivitis, episcleritis, scleritis.

How are these entities distinguished on history and examinations?

I know that they affect different "planes" surrounding the eyes but how do they look different. I have seen a lot of pictures in books that label things as any of the above but often I have difficulty telling them apart based on the picture.

Sometimes there are other clues that point me towards something. For instance conjunctivitis may also have lid swelling. Very occasionally I might be able to see the "darker" hue of scleritis. But a lot of the time I am just guessing what is what.

I have also read about using phenylephrine at 2.5% or 10% to check for blanching of vessels?

scleritis generally involves "real" pain, not just discomfort so that alone can help distinguish it, as well it is less common, and does not blanch well, maybe 10% or so. Vessles are also not so mobile as compared to more supericial layers. Lastly unless you are using a slit lamp and can put those findings into the context of the entire case presentation....then forget about scleritis entirely, refer it out. I wouldnt worry about trying to distinguish episcleritis vs conjunctivits, as they are often present for the same reasons. Epi generally will blanch 90%

 

[90 diopter]

I frequently see AC cell and flare with scleritis. Not seen in conjunctivitis and episcleritis.

 

[guttata]

I know that there are a lot of causes for the red eye but I was wondering about distinguishing between 3 things specifically: conjunctivitis, episcleritis, scleritis.

How are these entities distinguished on history and examinations?

I know that they affect different "planes" surrounding the eyes but how do they look different. I have seen a lot of pictures in books that label things as any of the above but often I have difficulty telling them apart based on the picture.

Sometimes there are other clues that point me towards something. For instance conjunctivitis may also have lid swelling. Very occasionally I might be able to see the "darker" hue of scleritis. But a lot of the time I am just guessing what is what.

I have also read about using phenylephrine at 2.5% or 10% to check for blanching of vessels?

You can usually distinguish scleritis from the others due to the severe, boring pain (with the exception of scleromalacia perforans) - that radiates around the eye. Symptoms are usually subacute - they start over a few days. Vision may be affected. Palpation will cause severe pain. On exam, the blood vessels will not blanch with 10% phenylephrine and not be mobile with a qtip. There may be a blue or violet hue (examine under normal lighting conditions). You may see areas of necrosis or scleral thinning. They may have cell/flare.

Episcleritis usually presents acutely (all of a sudden). There is very little pain. Vision is not affected. There is no tenderness on palpation. The blood vessels will blanch.

Conjunctivitis - you really need to distinguish the type - viral, bacterial, allergic, toxic.

Viral - these patients are very uncomfortable due to profuse tearing and photophobia. Will almost always become bilateral, with second eye involvement a few days later. May have matting in the AM. Possible recent URI. On exam, they will have enlarged pre-auricular lymph nodes. You will see a high tear lake along with follicles on exam. If severe, they can have severe eyelid edema. Wear gloves.

Bacterial - less commonly seen. Green/yellow thick discharge on exam. It is self-limited, but you always want to rule out N. gonorrhea.

Allergic - usually will have mucoid discharge with severe itchiness of both eyes. Papillae on exam (read about the difference between papillae and follicles). No nodes. May have tearing, but not profuse.

Toxic - always ask about eye drop use (OTC and prescription). No pre-auricular nodes. More papillary/follicular reaction inferiorly.

Always keep herpetic infections in your differential.

 

[KLPM]

By the way does anyone know of any books that are good for learning about how to work through ophthalmic problems based on presentation? A lot of books I come across are based on structures (e.g. cornea, retina) but is there anything that helps learn about how to evaluate someone who comes with red eyes or double vision etc.?

 

[guttata]

Wills Eye Manual